Amit Sahasrabudhe 2013-07-16 23:50:36
Medical Records: “The Devil is in the Details” Dr. Amit Sahasrabudhe is a board certified orthopedic surgeon specializing in sports medicine surgery and fracture care at the Arizona Sports Medicine Center (www.asmcmd.com). Dr. Amit is one of the team physicians for the Arizona Cardinals, Phoenix Coyotes, Colorado Rockies, and Chicago Cubs. He also takes care of several local area high schools. In addition to taking care of athletes and their families, his practice focuses on independent medical examinations for worker’s compensation cases as well as personal injury. He currently holds active medical licenses in Arizona and New Mexico. For more information or to get in touch with Dr. Sahasrabudhe, please feel free to call ExamWorks at (866) 800-4637. The medical record can be a very powerful tool. Documentation serves as proof that something did or did not occur. As physicians, we rely on a thorough history and physical examination to treat our patients. We take pride in accurate diagnosis and appropriate rendering of care. Often, we have to sift-through countless pages of records to “solve a problem,” particularly if the problem began a long time ago. So it begs the question – “How often do we miss something, an important detail, that was in fact written in the chart, but we just didn’t see it?” case in point I was recently asked to perform an independent medical examination (IME) on someone that had two work-related injuries. The 53-year-old female, originally sustained a work-related injury when she was 50 and working out of state. At that time, she tore her labrum extensively, and sustained considerable cartilage damage to the shoulder joint. It is a well-known fact in the orthopedic community that such an injury is likely to lead to the development and acceleration of arthritis. The patient underwent successful surgery to “fix” the labrum. At the time of surgery, the treating surgeon noted “severe osteochondritic changes of the glenoid.” Postoperatively, she never regained full range of motion. Three years later, while working for a different company, she tripped and fell at work. It was a groundlevel, low energy fall, but she sustained a contusion to the same shoulder. An MRI was interpreted by the radiologist as showing an extensive labral tear, significant osteochondrosis and a bone spur of the inferior humeral head. Two different orthopedic surgeons recommended shoulder replacement surgery and opined that the recent fall and the resulting contusion caused the findings noted in the MRI. Another physician performed an IME and concluded that a contusion would not cause a labral tear. A judge ruled that the recent fall caused the injuries noted on the MRI and awarded surgery to be related to the second injury. So who’s right? Who is responsible for the shoulder replacement? At this point, I was asked to perform an IME. The documentation in her medical records was excellent; unfortunately, several findings were never correlated. After her original injury, the surgeon noted “severe osteochondritic changes of the glenoid.” This is equivalent to arthritis. The word “arthritis” however, was never mentioned in her records. The radiologist who interpreted her MRI after the second injury noted significant osteochondrosis. Again, this was already reported by the initial surgeon. Of even greater importance is the presence of the bone spur on the inferior humeral head. It is well-known that this is indicative of fairly chronic shoulder arthritis. A ground-level, low energy fall would not cause arthritis, let alone the formation of a bone spur. It was opined that the fall would have caused the labral tear. Well-documented in the records is the claimant’s history of smoking. It is well-known and documented in the orthopedic literature that softtissue (labrum) healing is unlikely to occur in smokers and individuals over the age of 40; I opined that even without a fall, a new MRI would likely have shown a labral tear due to her history of smoking and her age at the time of surgery. Regarding her lack of motion, it was never correlated in all the records that someone with arthritis is likely to not have full range of motion. Furthermore, it was documented that she had a history of hypothyroidism, which is known to have a relationship with the development of a frozen shoulder. This was also not mentioned in her records. I opined that the claimant had arthritis prior to the second injury and already had loss of motion. A ground-level, low energy fall causing a contusion would not cause arthritis and would have no way of accelerating a process that was already there. Therefore a shoulder replacement would not be related to the second injury. After my IME, the judge changed her opinion, and ruled that the claimant already had arthritis and loss of motion. Surgery would not be related to the second work-related fall. Documentation was there all along; just in different words…the devil is in the details.
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